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Portal shunts.

Introduced in 1945, the portal shunt was the first definitive form of therapy used for patients who had bled from esophageal varices (varicose veins in the throat). It involves the surgical joining of two veins, the portal vein and the inferior vena cava, to relieve pressure in the vein carrying blood into the liver.

The portal shunt was quickly accepted and became the standard treatment by 1950. Its popularity began to wane in the 1970's for two major reasons. One was the frequency of encephalopathy (dysfunction of the brain) as a complication. The other was the failure of randomized controlled trials to establish a statistically significant advantage in survival for shunted patients over those treated with conventional, supportive, nonoperative management.

It was clear that the shunt operation in all studies virtually eliminated recurrent hemorrhage from varices. However, it did not enhance survival more impressively because of complications from the surgery, mainly encephalopathy and post-shunt hepatic failure. There is also an initial operative mortality of about 5 per cent.

Elective portal shunt surgery is performed in only a relatively small proportion of patients who have bled from esophageal varices. About one-fourth have such severe, uncontrolled hemorrhage that they either die quickly or require emergency surgery. Another one-fourth are considered poor surgical risks. Suitable patients for portal shunts are those who have bled from varices and who are relatively good candidates for major surgery. Shunt surgery appears to offer no benefits to patients who have not had variceal hemorrhages.

A more recently developed kind of shunt surgery is the distal splenorenal shunt (DSRS). This operation was devised to preserve the flow of blood through the portal vein to the liver while decompressing varices in the stomach and esophagus by means of the spleen and splenic vein. Studies comparing portal-systemic shunts with DSRS found similar rates of overall mortality and cumulative survival. DSRS had a higher operative mortality, but a lower rate of encephalopathy afterwards. Patients with alcoholic cirrhosis do poorly with DSRS compared to nonalcoholic cirrhotic patients. Other types of shunt operations are possible, but not judged as desir able in most cases.

A leading question among liver specialists during the past decade had been the relative value of the DSRS and scleropathy in preventing recurrent variceal bleeding. The major merit of scleropathy is that it is relatively easy to apply and can be administered at many primary care hospitals. Most physicians will use a flexible endoscope in order to inject dilute mixtures of sclerosing solution into esophageal varices. A recent study at Emory University supports the initial management of patients with cirrhosis and variceal bleeding by endoscopic sclerotherapy. However, it also shows that it takes surgical salvage of the one-third of patients who fail through sclerotherapy to achieve improved survival. The authors believe that in the broader clinical context, the occurrence of gastric variceal bleeding, hypertensive gastritis bleeding, or repeated esophageal variceal bleeding should be recognized early as sclerotherapy failures in order to permit appropriate surgical intervention. Correctly used in this combination, initial sclerotherapy and selective shunt may significantly improve survival in patients with variceal bleeding.
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Publication:Pamphlet by: American Liver Foundation
Article Type:pamphlet
Date:Sep 23, 1991
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Next Article:Primary biliary cirrhosis.

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